The ‘Treacherous’ Transition from a Great Tech Idea to Sustainable Business

Hyrax Biosciences recently developed Exatype, a software solution that enables health care workers to determine HIV positive patients’ responsiveness to treatment. The analysis is accurate, fast and affordable, making it especially useful in emerging economies and resource-limited settings. Here, Dr. Kirsten Miller-Duys, business development lead, talks about Exatype’s implications for global health, plans to turn it into a sustainable business and Africa’s emerging tech sector.

Kyle Poplin: What is precision medicine and how might it change global health?

Dr. Kirsten Miller-Duys (left): Precision medicine is about delivering the care that is best suited to you, your lifestyle and your specific disease. Currently, most of medicine is driven by evidence-based protocols from collated research results. At a population level this is fine but it may not be the best available treatment for you as an individual. Precision medicine is about understanding you – from your environment down to what is happening with your disease at a molecular level. So, how you and I are treated for the same disease may differ, as the way in which our disease is treated and managed will be the one which is most effective for us as individuals.

Genetic analysis is a big part of precision medicine. By interrogating your genes we can, for example, know that you have a susceptibility to a certain disease, or that you metabolise a drug in a certain way and therefore need more or less of the drug. At Hyrax Biosciences we focus on the genetics of your disease to find out which treatment your particular disease strain is most susceptible to. So we can tell you that the HIV virus in your blood is susceptible to XYZ available drugs by looking at the known resistant mutations.

We are only at the beginning of this journey so it is important to say that we really don’t have an understanding of the full consequences yet. But it does hold potential to make treatments more effective, reduce the duration and severity of illness, as well as limit nasty side-effects of treatments and, ultimately, save lives. It will mean cheaper health care and reducing things like antimicrobial resistance. There is a lot of focus on precision medicine at the moment. Projects like the Precision Medicine Initiative launched by President Obama in 2015 will go a long way to trying to understand this more. It aims to look in-depth at 1 million people to try and unravel some of the individual differences in acquiring, diagnosing and managing disease and wider health.

The danger is that this kind of targeted health care is just available for those fortunate enough to afford it. One of the big questions on a global health scale is how can we democratize precision medicine and expand the benefits it can bring to those who actually need it most? In the case of antimicrobial resistance this is not just about an individual’s treatment. Picking up and treating resistance diseases is vital to stopping them from spreading and becoming a public health crisis.

KP: What is Exatype and what problem does it solve?

KMD:In infectious diseases there are examples of many successful treatment programs. HIV treatment with ARVs (anti-retrovirals) is one such example. ARVs keep the virus suppressed to such levels that an individual is able to lead a relatively normal, healthy life while taking them. The treatment of bacterial infections with antibiotics is another example. Most of us assume that if we get a bacterial infection a course of antibiotic “wonder-drugs” will be able to treat it effectively and we can go on living as normal.

However, these gains are being threatened by the resistance which microbes are developing to commonly used drugs. We already see 5-15 percent of people on ARVs are resistant to their first line drugs; in the U.S. this figure is closer to 20-25 percent. We are seeing increasing levels of antibiotic resistance, evidenced by recent cases of resistance to colistin, a “last-line of defense” antibiotic for infections like E coli. Diseases such as tuberculosis are re-emerging as a significant threat because the level of multi-drug resistant (MDR) and even extensively drug resistant (XDR) strains is growing. The recent antimicrobial review run by the economist Sir Jim O’Neill estimated that if we do nothing about this, resistance will cost the global economy $100 trillion by 2050 as well as kill 10 million people annually.

So drug resistance is a big issue. One of the most effective solutions is to analyze the genetic makeup of a disease to accurately determine which drug works best against that microbe. This is where Exatype comes in: We make that analysis accurate, fast and affordable. Exatype is a computer software platform that takes the sequenced DNA data from a particular disease – say HIV – and quickly, accurately and cost-effectively analyses this data to inform clinicians of which drugs that disease is susceptible to. We allow a health care practitioner to know precisely which drugs the disease infecting a particular patient will respond to.

KP: How does Exatype work (in layman’s terms)?

KMD:There are specific mutations in the DNA of a virus or microbe which mean that it is resistant to a certain drug. Exatype works in four simple steps: the DNA data is uploaded (this can be done automatically from a device or is available to do online; it is aligned to what we call a reference sequence which shows us where the mutations (if any) in that DNA are; we link those mutations to what drugs they make the bug resistant to; and then produce a report for the clinician or researcher saying what drugs they can effectively prescribe.

The process and infrastructure we have developed are relatively disease-agnostic. So although we started out in HIV, we are now using Exatype for TB, staph aureus and even hepatitis C. Our focus is currently on infectious diseases but our very sensitive mutation detection would also be useful in things like microbiome analysis or for human oncology. So down the line we plan to include these areas, too.

KP: I read that Exatype is focused on emerging economies and resource-limited settings. Could you briefly discuss your business model and scalability, and how you ensure Exatype is affordable?

KMD:Exatype has developed out of the University of the Western Cape here in South Africa. Because of our context, we are faced with the reality of inequality. So our work, our ethos, is shaped by that. We are very focused on accessibility – how to ensure that technological and scientific innovations benefit as many people as possible, not just those lucky enough to be able to afford it.

At the same time we have to survive as a company, and as a startup. It is naive to assume that money isn’t important in sustaining this. So we are making our products available across public and private sectors and in developed as well as developing markets. For this we have a tiered pricing structure to allow for cross-subsidisation of our products. We also keep our cost base as low as possible; for example, using cloud computation instead of having to invest in our own servers and infrastructure. We are a small team so we make use of partnerships and collaborations to drive awareness of what we do.

In many parts of Africa our business development is actually market development. So we aren’t so much competing with other similar products as we are competing with old ways of doing things. (We’re) trying to advocate for investment in changing the way diagnostics is done so, for example, investing in DNA sequencing will stimulate the whole market and allow the most benefits to be realized by people on the ground. Initiatives such as the Universal Clinic being developed by the Institute for Transformative Technologies are examples of trying to solve the issue of actually getting these new technologies to be operationalized at a clinic level, ultimately where a molecular sequencing device should be.

KP: Exatype recently won second place in the Innovation Prize for Africa (IPA) competition, and U.S. $25,000. How big a deal and how motivating was that for those who have worked on the project?

KMD: It was a big deal for us to be recognized by the African Innovation Foundation through the IPA. We were included in a field of 10 finalists and the quality of innovations in that group was phenomenal. The judging process was also pretty intense. So, while we believe in what we are doing, it is also gratifying to get external validation. It helps keep the faith during the darker times, which there always are in startups! The money is being used to help grow Exatype – developing an “offline” version of the platform so it can be used in areas with little connectivity as well as a surveillance database to allow tracking of resistance trends.

KP: What are some of your goals as a company? How will you know when you’ve become successful?

KMD:Our overriding purpose is to translate advanced scientific research into tangible health benefits, ensuring these reach those who need them most.

‘Success’ for us is multifaceted and something of a moving target. I don’t think we are the kind of company that will ever sit down and go, ‘Wow, we have become so successful! I think we will always be looking ahead and pushing the boundaries to achieve more.

But we do look at how we are doing in four important areas: disease/market impact, scientific credibility and impact, our team and financial sustainability.

Disease impact is about ensuring access to advanced diagnostics so that we can make a difference to as many people’s lives as possible. One of the reasons our offering is available online is to ensure access is not an issue for anyone with an internet connection. Making our system as easy to use as possible and our tiered pricing structure are also about ensuring people can access the benefits. Of course, in Africa, infrastructure, transport and cost are huge system issues impacting access to health, so introducing point-of-care diagnostics like sequencers to where patients are, and providing accurate results while they wait, are key. We believe that the introduction of this kind of technology, at an affordable price, will be a game-changer in democratizing the use of health tech, so we are among the projects looking at how to do this. So when we can facilitate a health worker making a quick, accurate treatment decision for a patient while they wait – like what TB drug will work best for them – then we will know we are achieving.

It is also really important to us to maintain our scientific credibility. Three of the founders come from (and are still involved in) academic work in bioinformatics, and most of our customers and stakeholders evaluate us first from a scientific standpoint. Ensuring that what we produce is not only cutting-edge but stands up to hard scientific scrutiny is vital. The information we provide affects what treatment a patient is on, and whether that works or not, so we have a responsibility to ensure that the most accurate and sensitive information available is made available to the health care provider.

We have only been able to do what we have because we have a phenomenal team who work really well together, are really exceptional in their field, love what they do and believe in the wider purpose. So certainly part of our success is maintaining and growing this passionate, focused team. It’s difficult to put hard metrics to but having a happy, functional team is vital.

And, of course, success is also about being a profitable business, so we have related financial milestones to know how we are doing in this area. Mainly it is about being able to sustain and scale so we can continue to develop and get the best people along for the ride.

KP: You’re a South African company. Is it fair to say that Africa’s tech sector is emerging? If so, what explains the emergence? Might we expect more innovations on the horizon?

KMD: Tech in Africa is definitely on the rise. … Africans are resourceful; we know how to do a lot with a little. And technology, the internet and mobile devices are the ultimate tools to facilitate this. There are now 314 active tech hubs in Africa, double the number from a year ago, so we are a continent on the rise.

Why the emergence? I think it is an interception of need, skills and resources. Obviously, the need in Africa is great, so the demand is there. And all too often the products and services offered by big tech companies in the developed world are irrelevant to the way things work in an African environment. So, as we saw at the IPA, Africans design and develop solutions that make sense to them and have real traction and impact in their environment. Also, our younger generation is getting skilled; many realize that technology offers boundless possibilities and they don’t want to be left behind. So there is a hunger to achieve and a real passion, something often missing in other parts of the world. And I think it is a positive feedback loop – the more people start using technology, the more people innovate and set up companies, they create examples and, importantly, networks for others to do the same.

But we still need more education, investment, infrastructure and support. Looking at the sort of resources – the guidance, infrastructure and systems – available in places like the UK and the U.S. for health startups, we are still far behind. So a lot more needs to be done in terms of identifying and then supporting the tech innovations. I think the development of networks of innovators, entrepreneurs, funders and investors providing guidance and support is key. The transition in tech from great idea to sustainable business is a treacherous one, even in an environment of great funding and support. In Africa it is still leagues more treacherous and lonely and this needs to change.